This thesis explores the appropriateness of suitably trained children's nurses undertaking the pre-operative assessment of children prior to day case and minor surgery. The central focus of the study is a 60 subject hypothesis refining randomised controlled trial (RCT), comparing the pre-operative assessment of children carried out by suitably trained nurses with the assessment carried out by senior house officers (SHO's). Findings demonstrate significantly greater accuracy by nurses in the detection of abnormalities in children's history, when compared with the SHO's. No significant difference is demonstrated between the performance of nurses and SHO's in detecting abnormalities within the physical examination, or in the correct identification of children who have no detectable abnormalities. However, these findings of 'no significant difference' must be substantiated within a larger equivalence trial before assurances can be given that paediatric pre-operative assessment might safely be transferred from SHO's to nurses. Supplementary data explores the perspectives of parents and practitioners with regard to children's nurses undertaking a pre-operative assessment role. The views of parents, gathered via questionnaires, are supportive of the initiative. The views of nurses and SHO's involved in the RCT are similarly supportive, although the conduct of in-depth interviews with the nurses also reveals insights into their perceived vulnerability when carrying out such expanded roles. The views of anaesthetists are less positive, and convey a reluctance to accept nurses carrying out the pre-operative assessment of children. Finally, a national survey explores the views of nurses and SHO's involved in paediatric pre-operative assessment, revealing that nurses attribute significantly greater importance and enjoyment to the pre-operative assessment role when compared with SHO's. This factor may in part explain the greater accuracy demonstrated by nurses in the RCT, but such speculation must be substantiated by further enquiry. This study contributes to the nursing literature in offering what is thought to be the first systematic UK exploration of the role of the paediatric nurse within pre-operative assessment. It is also the first study, as far as the author is aware, to demonstrate significantly greater accuracy in history taking by nurses when compared with doctors, in a paediatric specific UK study. It therefore makes a meaningful contribution to both the paediatric and expanded role evidence bases. It also offers systematically informed hypothesis generation to underpin the ongoing exploration of an expanded nursing role within paediatric pre-operative assessment.

This study was carried out in response to the policy attention directed at older people discharged from hospital with ill-defined conditions, or signs and symptoms related disease. In England there has been an increase in incidence of this type of hospital admission and policy suggests that patients with these codes have fewer medical/physiological and more ‘social’ conditions that could be better managed in community settings. Currently however, this population has not been characterised. Description of the functional and physiological status of these patients is essential for the planning of future health and social care services. Patients with ill-defined conditions were described via a cross-sectional study of 80 patients aged over 70 years admitted to hospital with collapse/falls. Number of chronic diseases and prescribed medications were obtained from the medical records. Routine blood tests were taken and serum cytokine concentrations (IL-1β, IL-6, TNF-α, IFN-γ) were measured. Deprivation score, functional status, depression and the prevalence of frailty were ascertained. 35 patients received ill-defined condition codes, 45 received other codes. Patients with ‘illdefined conditions’ had normal routine blood results but very high serum concentrations of pro-inflammatory cytokines which did not correlate with number of chronic diseases indicating considerable medical problems. As the policy had suggested, they also had prevalent functional impairment (65.7%), high rates of frailty (77.1%) and pre-frailty (14.3%), and depression (42.9%). Patients with ill-defined conditions had poor outcomes evident in the high readmission (60%) and mortality (20%) rates. Patients were hospitalised for a statistically significantly shorter period than patients with other codes (p<.05) and functional limitations and depression were associated with a longer length of stay. Increasing deprivation and TNF-α concentration were associated with an increase in the odds of an illdefined condition diagnosis at discharge. The association between functional limitations, frailty, chronic disease and depression add considerable complexity to the health of older people with ill-defined conditions. However, the prevalence of multiple morbidity, high serum concentrations of inflammatory markers and poor outcomes indicate that they also have considerable medical problems that may be largely unmet. These medical problems may result from chronic disease symptom crises and manifest as geriatric conditions for which there are no appropriate International Classification of Diseases (ICD-10) codes. The results of this study indicate a need for reevaluation of the ICD-10 system to incorporate the health problems faced by older people and further research into the effect of a more comprehensive community-based chronic disease management that aims to enable frail older people to maintain health and independence at home and prevent readmission in patients with ill-defined conditions.

Chronic neck pain can occur in a proportion of individuals who have suffered a whiplash injury and also in individuals that have not experienced a trauma to the neck. The mechanisms that cause chronic pain are unclear, and whether they differ in traumatic or non-traumatic onset is unknown. A review of the background literature identified differences in muscle activation for individuals with chronic neck pain, following a whiplash injury and from a non traumatic onset, compared to healthy controls. However, differences in the combined action or synergy of superficial neck muscles in these chronic neck pain groups, during non-forced activities, had not been widely reported. A new methodology was developed to address this area of research. A pilot study was undertaken to establish the reliability of the method and to identify areas for refinement. The main study employed the refined methodology to determine possible differences in activation and synergies of the upper trapezius and sternocleidomastoid muscles, alongside correlations of subjective pain and fatigue with surface electromyographic measures, using linear array electrodes. Some differences in muscles activation and synergy were observed between the groups. Individuals showed different strengths of relationships between subjective and objective measures and different proportions of significant correlations were shown between groups.

Introduction: Clinical Leadership is a way of facilitating change and increasing the quality of care at the front line of practice. However, the failure of midwifery leadership and being designated an oppressed group questions the ability of midwives to practice as clinical leaders in the labour ward environment. Whilst there is some research relating to clinical leadership in nursing, no research exists that investigates the clinical leadership of midwives who are directly involved in giving care to women. Aim: The aim of this research was to explore clinical leadership on the labour ward and to develop an understanding of the associated characteristics of clinical leadership. The attributes that delineated effective clinical leadership were examined in addition to associated professional discourses and relationships of power that existed on the labour ward. Methods: A critical ethnographic approach was undertaken on the labour ward of a district general hospital and a teaching hospital in the North of England, using participant observation and semi-structured interviews. A total of sixty-nine hours of participant observation was undertaken. A purposive sample of 30 midwives were interviewed in the first instance and further interviews were undertaken with 18 midwives who were nominated as effective clinical leaders by the midwives in the initial interviews. Data were examined through the lens of Bourdieu’s Theory of Practice. Findings: Clinical leadership existed at different levels on the labour ward, however, midwives mostly identified LWCs in this role. LWCs’ clinical leadership was necessary, contradictory, gendered, socialised and unsupported within the hierarchical, high-risk and fearful labour ward. A combination of heroic and values-based clinical leadership was required to maintain safety and facilitate productivity. Heroic leadership, the high level of accountability and symbolic capital invested in the LWC led to a loss of autonomy for other midwives, a lack of dissent and difficulty initiating changes in practice. The contradictory nature of the LWCs’ work and a lack of support led to them experiencing both emotional and physical stress. Within an increasingly highrisk labour ward environment the LWC clinical leaders experienced professional misrecognition and discrimination that resulted in dysfunctional inter-professional relationships and keeping the obstetricians away from women. Conclusion: A high level of responsibility invested in the LWC combined with socialisation led to heroic leadership which fostered dependency prevented change and innovation. Inequalities of power and dysfunctional relationships were symptoms of a system failure that does not support midwifery practice or woman-centred care. Recommendations are made for policy, education, practice and future research.

This study explores the mental health nurse’s experience of ethical reasoning while overriding the choices of mental health service users within an acute mental health context. When working with service users in acute mental distress a mental health nurse’s clinical decisions will have a controlling element, which can lead to the service user’s freedoms being restricted. This power to restrict freedoms also known as coercion can be explicit, it follows the rule of law, and implicit; ways of controlling that are ‘hidden’. The ethical use of this power requires the nurse to be an effective ethical reasoner who understands both the explicit and implicit nature of this power. Coercive power, which is explicit, has been thoroughly explored; however, there is limited work exploring the use of this power within an ethical context and as a ‘real-time’ practice issue. In addition, there is little work exploring implicit power as a practice issue or as an ethical issue. To examine this knowledge gap this study adopts an interpretative phenomenological analysis (IPA) approach to engender an understanding of the mental health nurse’s personal meaning and experience of using both explicit and implicit coercive power. This approach affords the researcher the opportunity to tease out the personal ‘ethical’ meaning of the participants’ experiences by facilitating an in-depth and sensitive dialogue, which focuses on stimulating conscious ethical reflection. IPA is an idiographic mode of inquiry where sample purposiveness and analytical depth is more important than sample size. On this basis, six qualified mental health nurses were recruited who have used coercive strategies while nursing service users in acute mental distress. The semi-structured interviews were thematically and interpretively analysed, the five superordinate themes that were generated are; the nurse as a practitioner, their values, their practice, their use of coercion, and their ethics. In addition, the results of the study highlighted that coercive strategies are a key part of a mental health nurse’s daily practice both explicitly and implicitly. These strategies can be beneficent; however, this is dependent on the ethical reasoning ability of the nurse and the professional support they receive in practice. Being an effective ethical reasoner requires the nurse to acquire ‘good habits’, a basis for enabling the nurse to work through an ethical challenge in ‘quick time’. Furthermore, to enhance these good habits they also need to have an ‘ethical imagination’. Considering these points, this study recommends mental health nurses when using coercive power use a multi-faceted ethical reasoning approach. This approach should aim to create good ethical habits through continually rehearsing good responses to common practice issues. In addition, this approach should not neglect the need for the nurse to use their ethical imagination and to feel for an ethical solution where required. As a future area for research, this study recognises the skilled use of ethical imagination in the field of mental health nursing requires further exploration.

Aim and background: this study investigates faculty members’ perceptions of the impact of Impact of the leadership styles of nursing deans on the job satisfaction of faculty members working in nursing education in Oman. Nursing education in Oman currently is going through a major transformation, with the appointment of new deans, the introduction of an accreditation process, and the upgrading of the nursing diploma to a Bachelor’s degree program in all governmental nursing institutions. These reform require significant development work in a short period of time; various taskforces have been established with specific tasks such as curriculum restructure, improving the range and number of research activities, the merging of institutes, introducing new policies, and establishing a quality assurance approach. This reform programme demands effective leadership to lead faculty, build the vision and respond to a range of external demands. In Oman, there is a lack of research on the role of leadership in higher education and its importance to staff professional development and job satisfaction, which in turn reflects on the level of organizational performance. The significance of this study is that it explores the perceptions of both teaching staff and their deans in a comparable set of organizations to determine which leadership styles have the greatest potential to improve their organizations. This was an insider research project with the researcher being a nursing dean; however certain measures were taken to ensure validity and reliability of the study. Method and conclusion: The study involved 147 lecturers and 7 leaders from various nursing institutes in Oman. Data were collected through semi-structured interviews and questionnaires: the Minnesota Satisfaction Questionnaire (Weiss 1967) and the Multifactor Leadership Questionnaire (Avolio & Bass 2004). Qualitative data were analysed for recurring themes and coded accordingly. Coding categories were constructed from the concepts and themes that emerged during the interview process and from the review of the literature. The overall findings indicate that most faculty members are satisfied with the leadership style of their deans. The transformational leadership style emerged as the preferred style to ensure faculty satisfaction and maintain productivity levels in demanding times; however, the deans also used a transactional leadership style for specific tasks. Implications: Management roles in health care education are very demanding, thorough preparation is required for the dean’s role and its associated tasks in order to develop and sustain a transformational style. Work-related leadership training and skill-development workshops, mentoring, and survival skills workshops could provide new deans with much needed support. The research on transformational leadership provides a good starting point; however, we need to think of the next step. It is very clear that deans of nursing institutes need to adopt transformational-transactional leadership styles to overcome continuous challenges, satisfy the nursing faculty and boost organizational productivity. Hence, the role of the nursing dean in Oman has to be built on transformational leadership, with a focus on collaboration by adopting a distributive stance (distributed leadership) that focuses on learning.

No description available.

The present research used van Manen's application of hermeneutic phenomenology as philosophy and method to explore stroke rehabilitation experience across two different settings, i.e. (i) a conventional setting (National Health Service or NHS stroke unit) and (ii) an unconventional setting (Conductive Education or CE). Interviews, observations and reflective diaries were used to collect data on 24 volunteering stroke patients' experiences. High levels of dis empowerment and negative images of self as well as the nature of motivation were indicated to be thematic of stroke rehabilitation experience in the stroke unit. In the CE setting stroke rehabilitation experience was characterised by increased selfconfidence, unconditional positive regard from conductors, challenging activities and body-half integration. A juxtaposition of stroke rehabilitation experience in the CE setting with stroke rehabilitation experience in the NHS stroke unit brought to light an important difference between the physical body-split caused by stroke, and a much wider and deeper disintegration of being. The juxtaposition further indicated that (i) the approach used in the NHS stroke unit is biomedical in spite of the presence of a multi-disciplinary team, and (ii) that the one adopted by CE is a person-centred approach characterised by holistic principles, with an overall focus on mobility. A reflective evaluation of this hermeneutic phenomenological study ensues, including a discussion on the difference between person-centredness and holism. The better understanding gained regarding stroke rehabilitation experience across the two settings was then used to make recommendations regarding what could constitute a holistic approach to stroke rehabilitation. Finally, the researcher's experience of 'being-immersed' in others' lived experiences was discussed in order to illustrate the holistic effect the research process had on the researcher's well-being, and the development of a tool which addresses researcher emotions holistically is also presented.

Psoriasis is a chronic skin disease that affects up to 2% of the UK population. The clinical presentation ranges from mild disease to extensive, severe disease that causes considerable discomfort and distress. Severe disease usually requires photochemotherapy or systemic treatment. Information about the effectiveness, safety and costs of the different treatments is required to enable dermatologists to formulate evidence-based treatment guidelines. Systematic reviews of the four main treatment modalities for moderate-severe psoriasis (cyclosporin, methotrexate, systemic retinoids and photochemotherapy) were performed. Randomised controlled trials were located systematically by electronic searching, hand searching and personal communications. Data on trial characteristics and outcomes were extracted and tabulated. Where possible data were pooled to give summary effect sizes as odds ratios, rate differences or numbers needed to treat (NNTs). Firm RCf evidence of efficacy was found for cyclosporin, oral ret.inoids, particularly in combination with PUV A, phototherapy, photochemotherapy and for combinations of topical calcipotriol or steroids with phototherapy. The corresponding NNTs were low, indicating high levels of efficacy. RCI' evidence of efficacy is lacking for methotrexate. Two observational studies of patients attending the Psoriasis Specialty Clinic were performed. The first was a crosssectional study that used data in existing disease assessment docwnentation to identify the characteristics of a group of 256 patients. The second was a longitudinal study that followed the treatment pathways of 166 patients in the first group. These studies confirmed that this group of patients and their treatments were comparable with those described in the literature. An economic analysis was performed, using a previously published decisionanalytic model, to compare four treatment strategies for severe psoriasis from the health service perspective. The results (cost-effectiveness ratios) showed that methotrexate was the most cost-effective primary treatment followed by cyc1osporin, acitretin and PUV A. The rank order was not sensitive to changes in response rates. Modifications to the decision analytic model are proposed including a wider array of pathways and an allowance for adverse effects of treatment. Future analyses should include narrowband UVB alone as a primary treatment.

Fitness to Practise (FtP) is an emerging area of interest within the health and social care field due to the increasing high profile cases relating to professionalism and conduct of practitioners. Research has ‘yet to catch up’ with the emerging interest and the current body of evidence predominately consists of literature reviews and descriptive or discursive papers which examine the process and functionality of FtP panels. Currently no research has attempted to examine the decisions made or indeed how these decisions were arrived at within the following health and social care professions, Nursing, Paramedic Practice and Social work. Professional regulation for each of these professional groups is established through regulatory bodies. The regulation and determination of FtP of students on leading to registration is the role of the Higher Education Institution (HEI) and is less uniform in its approach. This may lead to disparity and the potential risk of inconsistency, unfair and unjust decisions for students. Aim: In order to gain a greater understanding FtP and professional conduct, this research study aimed to examine the decision-making process involved in ‘FtP’ panels for undergraduate health and social care students, comparing the decision-making process of students, lay person and practitioners (both experienced and inexperienced). This study explored the factors that influence the decision-making processes including experience and skills. Methods: Three simulated ‘FtP’ case studies were created and filmed to examine the decision-making process that takes place in panels for undergraduate nursing/paramedic/social work students. These were informed by real life cases and expertise of professionals within each of the professional groups. Actors were recruited for each of the case studies and the simulations were filmed. Debriefing of the simulation was conducted with the actors and the data collected was analysed using thematic analysis. The case studies were then examined and deconstructed by four focus groups for each case (twelve in total) with degrees of experience, lay people and students. This deconstruction also included an evaluation of the simulation and its potential use in the field of FtP. The data collected was analysed using thematic analysis and key emergent themes were identified. Findings: The findings highlighted two key areas. Firstly, the importance of those involved in panels, 'the people involved in FtP panel' and secondly the ‘decisions that were made during the panels’. These findings suggest that there are a number of identified roles within FtP. The influence of these roles is measured not by the role but the execution of the role and personalities are more influential than identified roles. There is a further suggestion that experience of FtP panels can influence decision-making processes and can make for lengthy yet robust decision-making and that when systematic approaches to decision-making are employed that there is clearer understanding of decisions it leads to more effective decision-making processes. Conclusion: Understanding student FtP decision-making and the influential factors involved in that process will inform HEIs in the overall management of FtP and consequently promote consistency and fairness in decision-making. This will be achieved by recognising the influential factors on the processes of FtP and considering these when FtP are conducted. It should prompt attention to the approaches adopted by individuals during FtP and the need for a more uniformed approach to FtP not dissimilar to that of the regulatory bodies approach. Implications: Recognising that personalities as well as identified roles are influential in the decision-making is important to consider when HEIs reflect panel composition. It is also essential to consider the experience and the skill when selecting panel members for FtP.